Evaluation of guidelines for observational management of cervical intraepithelial neoplasia 2 in young women.

BACKGROUND: A high rate of regression in young women with cervical intraepithelial neoplasia grade 2 has been recorded. However, there are few prospective data by which to evaluate management guidelines. OBJECTIVE: This study evaluates the American Society for Colposcopy and Cervical Pathology recommendations for follow-up of young women with cervical intraepithelial neoplasia 2 using data created by a large prospective multicenter study of observational management. MATERIALS AND METHODS: Participants were 616 women under 25 years with biopsy-diagnosed cervical intraepithelial neoplasia 2 following a referral to colposcopy for an abnormal smear with no previous high-grade abnormality. The protocol included colposcopy, cytology, and colposcopically directed biopsy at the initial visit and at 6- and 12-month follow-ups visits, and these data were analyzed. Histology from the corresponding cervical biopsy was treated as the reference diagnostic test. For young women with cervical intraepithelial neoplasia 2, we aimed to determine the following: (1) the ability of colposcopy to identify women with cervical intraepithelial neoplasia 3 or worse at 6 months; and (2) the ability of colposcopy, cytology, and a combination of cytology and colposcopy to identify residual high-grade abnormalities at 12 months. In addition, although not specified in the guidelines, we investigated the ability of high-risk human papillomavirus positivity alone or with cytology as a co-test to identify residual high-grade abnormalities at 12 months. RESULTS: At 6 months, cervical intraepithelial neoplasia 3+ colposcopic appearance identified only 28% (95% confidence interval, 18-40%) of women diagnosed with cervical intraepithelial neoplasia 3. At 12 months, a high-grade colposcopic appearance identified only 58% (95% confidence interval, 48-68%) of women with residual histological cervical intraepithelial neoplasia 2 or 3. At 12 months, high-grade cytology identified only 58% (95% confidence interval, 48-68%) of women with cervical intraepithelial neoplasia 2 or 3. However, the combination of either high-grade cytology or colposcopic appearance proved substantially more sensitive (81%; 95% confidence interval, 72-88%). High-risk human papillomavirus positivity at 12 months was a sensitive (96%; 95% confidence interval, 89-99%) indicator of persisting high-grade histology. However, this sensitivity came at the expense of specificity (52%; 95% confidence interval, 45-58%). A co-test of high-risk human papillomavirus positivity or high-grade cytology at 12 months provided a high sensitivity (97%; 95% confidence interval, 90-99%) but low specificity (51%; 95% confidence interval, 45%-58%). CONCLUSION: Colposcopy and cytology are limited in their ability to exclude persistent high-grade abnormality for young women undergoing observational management for cervical intraepithelial neoplasia 2. We recommend biopsy for all women at 12 months. High-risk human papillomavirus positivity is a sensitive indicator of persistent abnormality and should be considered in those not having a biopsy.

Increasing incidence of endometrial carcinoma in a high-risk New Zealand community.

BACKGROUND: Endometrial carcinoma (EC) is increasing in incidence, attributed largely to the obesity epidemic. Ethnic differences in New Zealand have long been recognised, with Pacific women bearing the greater burden of disease. We hypothesise that the pooled national incidence rates underestimate the true burden of EC in our high-risk community. AIMS: We aimed to: (1) determine the incidence, trends and outcome of EC in the high-risk community served by our hospital, relative to national data; and (2) examine associated demographic, and clinicopathological features with reference to risk factors, to identify potential clinical and population intervention points. MATERIALS AND METHODS: All area-resident women treated for EC at Middlemore Hospital from 2000 to 2014 were identified from records, and clinicopathological data obtained. Incidence and time trend analyses were performed with reference to tumour type, age and ethnicity. RESULTS: The study included 588 women. Pacific, followed by Maori, women had the highest incidence of EC (relative risk = 5.11 and 2.47, respectively, relative to 'Other' women). The incidence increased for all ethnicities (annual percentage change (APC) of 7.3; 95% CI 3.6-11.1), most marked in women aged below 50 years (APC of 12.2; 95% CI 5.2-19.7). This occurred predominantly in Pacific women, who had a high prevalence of potentially reversible risk factors. Disease-specific survival was worse in Pacific, and to a lesser extent, Maori women. CONCLUSIONS: Prompt investigation of symptomatic, high-risk women regardless of age may detect endometrial abnormalities at an early, potentially reversible stage. The prevention and management of identifiable high-risk factors would help mitigate the risk of EC and associated diseases.

Impact of human papillomavirus vaccination on rates of abnormal cervical cytology and histology in young New Zealand women.

AIM: Determine the impact of quadrivalent human papillomavirus (HPV) vaccination on abnormal cervical cytology and histology rates in young New Zealand women. METHODS: Retrospective population-based cohort study of women born 1990-1994, with a cervical cytology or histology recorded when aged 20-24 between 1 January 2010 and 31 December 2015. Data was obtained through linking the National Immunisation Register and National Cervical Screening Programme Register. RESULTS: N=104,313 women (376,402 person years of follow up) were included. The incidence of high-grade cytology was lower in vaccinated women (at least one dose prior to 18 years) than in unvaccinated women (8.5 vs 11.3 per 1,000 person years [p1000py], incidence rate ratio [IRR 0.75], 95% CI 0.70, 0.80, p<.001). The incidence of high-grade histology was lower in vaccinated women than in unvaccinated women (6.0 vs 8.7 p1000py, IRR 0.69, 95% CI 0.64, 0.75, p<.001). There was no evidence of a difference in the incidence of high-grade histology between European and Maori women overall or after taking vaccination status into account. CONCLUSIONS: Receiving at least one dose of quadrivalent HPV vaccine prior to 18 years was associated with a 25% lower incidence of high-grade cytology and 31% lower incidence of high-grade histology in women aged 20-24 years.

A review of cervical cancer occurrences in New Zealand 2008-2012.

BACKGROUND: A review of the screening histories of women/wahine diagnosed with cervical cancer was undertaken to assess where the screening pathway can be improved. METHODS: Women diagnosed with confirmed or possible cervical cancer during 1 January 2008-31 December 2012 were identified from the National Cancer Registry (NCR) records. Screening histories for these women were obtained from the National Cervical Screening Programme (NCSP) Register along with pathology and cytology reports and staging information. Women aged 25-69 years with confirmed cervical cancer underwent a review of their screening history. Cervical cancer incidence rates were calculated using Statistics New Zealand mid-year population estimates. RESULTS: Seven hundred and seventy-two confirmed diagnoses of cervical cancer were made during 2008-2012 for an incidence rate of 6.9 per 100,000 women per year. Only 13% of 644 women aged 25-69 years had regular cervical cancer screening according to New Zealand guidelines and this proportion was lower among Maori and Pacific people and those living in deprived areas. However, 37% of women had had a screen in the preceding three-year screening interval, excluding screens undertaken within six months of histological diagnosis. In addition, a significant number developed cancer following an abnormal screen. CONCLUSION: Ongoing efforts are required to improve uptake of regular cervical screening particularly for Maori and socio-economically disadvantaged women/wahine. Further investigation of incident cervical cancers using population-linked data, slide reviews of screens reported as negative and more clinical information is needed to facilitate clinical pathway review to determine the contributing factors that lead to the development of cervical cancer following normal and abnormal screening tests.